Provider Demographics
NPI:1255596862
Name:DIANA'S BOARDING HOME, INC
Entity type:Organization
Organization Name:DIANA'S BOARDING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:F
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-238-3344
Mailing Address - Street 1:HC 64 BOX 4590
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-9408
Mailing Address - Country:US
Mailing Address - Phone:573-866-2010
Mailing Address - Fax:573-866-2100
Practice Address - Street 1:HC 64 BOX 4590
Practice Address - Street 2:
Practice Address - City:MARBLE HILL
Practice Address - State:MO
Practice Address - Zip Code:63764-9408
Practice Address - Country:US
Practice Address - Phone:573-866-2010
Practice Address - Fax:573-866-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3009749320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM266733500Medicaid